Helsana report: Coronavirus
Fact check on medical care during coronavirus

With Switzerland still adjusting measures against coronavirus and discussing vaccinations and easing of restrictions, we take a look back: what was medical care provision like in the first year of the pandemic? The facts both contradict and confirm widely held and sometimes speculative opinions, and show the impact coronavirus has had on our healthcare provision.

What was the experience of patients with cardiovascular problems, chronic disease or mental illness? Did their situation deteriorate, and did they receive effective medical care? The coronavirus report takes a critical look at healthcare provision in the context of coronavirus, and provides new facts. Based on anonymised data from around 1.4 million persons insured with Helsana, the report shows how the areas of “emergency care”, “care for chronic patients”, “mental health” and “elective treatment” were affected. All data and figures are extrapolated for Switzerland as a whole, and are therefore representative of the overall population. In addition to this web report, the complete analyses are also available for download. This overall view allows for an objective discussion and lays the foundation for further analysis.

Benefit costs and COVID-19 hospitalisations


1. Lockdown
2. Wave
OKP benefits (CHF millions)
Number of hospitalizations
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Source: FOPH, Helsana Helsana
Developments in basic insurance costs in 2020 compared with 2019, as well as laboratory-confirmed hospitalisations due to COVID-19. The different benefit areas can be shown/hidden via the menu.

1. Costs changed very little in the coronavirus year

Like many other countries, Switzerland was caught relatively unprepared by the World Health Organization’s warnings last year. Major restrictions were imposed in many areas of private, business and public life order to prevent the health system from collapsing.

The Swiss authorities imposed a six-week ban on non-urgent treatment to free up hospital beds and staff capacity, and issued “stay-at-home” instructions to contain the spread of the virus. The approach paid off; while the health system reached its limit in certain areas, even in the first wave there was always spare capacity. But how did the pandemic affect cost developments? An initial estimate by the Federal Council indicated that there was CHF 300 million in direct costs for basic insurance due to hospitalisations and tests in connection with COVID-19. In addition, an amount in the low eight figures was incurred for outpatient costs of COVID-19 sufferers with symptoms.

 

  CHF

Testing costs: approx. 50 million
Acute care hospital ward: approx. 160 million
Acute care hospital intensive care unit: approx. 90 million
Total: approx. 300 million
Pandemic-related costs for health insurers. Not included are outpatient treatment costs due to COVID-19. Source: Federal Council.

“Helsana’s evaluations do not allow any direct statements to be made about under- or over-provision. It appears to be at least plausible that both necessary and unnecessary treatments were reduced during the six-week lockdown in the health system. In general, the question is whether there was any negative impact at all in the provision of elective interventions and basic care in the medium term, as it seems that much of this was offset over the year as a whole.”

Professor Milo Puhan. Director of the Epidemiology, Biostatistics and Prevention Institute at the University of Zurich

Society has learned to deal with the pandemic

The total costs in basic insurance remained practically unchanged compared with 2019. They fell significantly under the ban on treatments during the first wave, a time when patients were also uncertain and their behaviour was influenced by fear of infection. This first phase was followed by a slow increase in costs. While the second wave was much more severe than the first, it did not result in another slump, suggesting that the health system and the population had learned to deal with coronavirus over the course of the year.

 

However, cost developments varied in the individual areas of medical care. In the first wave, all areas provided significantly fewer services compared with the previous year. This resulted in a significant decline for some (e.g. basic care providers or hospitals), with negligible declines for others (e.g. specialists). By contrast, laboratory services, for example, actually increased.

Costs, young and old

In general, the older the insured person, the more frequently they use health care services and the higher the average costs.

More young people received medical services, but less often and the services were less expensive.

In general, medical treatments increase with age, as do the average costs. This logic was confirmed once again in 2020. What is striking, however, is that in comparison with the previous year, the share of “new” recipients, i.e. those with at least one benefit claim, increased among younger people (20-49), while the average per capita costs in this age group decreased. The regulatory testing requirement and the restrictions in the health system are likely to have led to this effect. In this extraordinary year, the decline in costs would have been much higher without the additional coronavirus benefits, especially among adolescents and young adults.

The youngest insured persons below the age of 10 generated significantly lower benefit costs in 2020 than in the previous year. This age group had less contact with pathogens than usual due to increased amount of time in the care of parents, and intensified hygiene measures. On top of this, further analysis indicates that at least some routine examinations and recommended basic vaccinations were also postponed, again leading to lower costs.

 

Older people were less able to do without regular medical care

A supplementary analysis excluding the costs associated with persons who died in the years under review reveals that costs rose steadily for the over-60s in 2020. The older the person, the bigger the difference on the previous year. The higher costs can be explained by the fact that the over-60s, as the largest part of the risk group, have long been the most affected by COVID-19. Their intensive, long-lasting and thus also costly treatment became particularly relevant with increasing age, and fewer services could be omitted from regular care than for younger people.

Difference in OKP benefits


Source: Helsana
Change in benefit costs per insured person between 2019 and 2020 of the total population by age group, with and without exclusion of the deceased.

2. Telephone and video consultations will need to play a more significant role in future

The mobility restrictions right at the beginning of the first wave called for alternative means of communication – not only in our private and professional lives, but also in the health system.

In this context, (video) telephone communication made an important contribution, in many cases allowing patients to maintain contact with doctors, physiotherapists and psychiatrists, and the provision of distance therapies.

 

Consultations via telephone and video are both possible and popular

Telephone and video consultations have also played an important role in basic medical care, with a particularly sharp increase during lockdown and the period thereafter.

“A great deal has been learned from the crisis. And that is what has become evident in recent months. Even if it was sometimes very unpleasant for society and the economy. The challenge now is not to forget the insights, and to make the best use of them for the future.”

Professor Thomas Szucs. Chairman of the Board of Directors of Helsana and Director of the European Center of Pharmaceutical Medicine at the University of Basel

In a period characterised by great uncertainty and limited mobility, the option of the telephone proved to be an important treatment alternative. While such approaches were rarely used before the pandemic, the aim now is to pave the way for the future based on the positive experience of 2020, and establish an appropriate charging system. Treatment by telephone helps to ensure more efficient care for problems that do not require on-site presence, and can contribute to better and more efficient care for rural areas or less mobile patients, for example.

Basic care consultations, 2020


1. Lockdown
2. Wave
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Source: Helsana
Change in the number of consultations according to consultation type among basic care providers.

3. Medical care in the face of coronavirus

To avoid overburdening the health system, all non-urgent interventions, treatments and examinations were banned at the beginning of the pandemic. For certain health events, however, treatment cannot be delayed or halted by official restrictions.

Our analysis focuses on some of these “scenarios”, and examines whether the pattern of care changed during the pandemic. These are the areas of “emergency care”, “chronic care”, “mental health” and “elective treatment”. While the first two areas are unlikely to have changed a great deal in 2020 compared with the previous year, the area of mental health is more likely to have seen an increase due to coronavirus, and elective treatments at least a temporary decline.

Were there more heart attacks in 2020?

Acute emergencies require immediate medical intervention. In 2020, however, significantly fewer heart attacks were examined in Swiss hospitals than in the previous year.

Although the decline was particularly pronounced during the first wave, it continued throughout the rest of the year. . The number of hospital cases in which only diagnostic tests were carried out almost halved over the year compared with 2019. This does not include cases in which a coronary intervention followed hospitalisation (e.g. coronary dilation/stent implantation).

 

The more serious the acute cardiovascular emergency, the lower the decrease in cases. The same pattern was also seen in appendicitis. The more easily recognisable and clearer the serious medical emergencies were, the more similar the case numbers were to those of the previous year. It can therefore be assumed that certain milder cases with non-specific symptoms may have received insufficient care in 2020. In the context of conditions such as appendicitis, however, less serious cases may have been treated on an outpatient basis. Improved triage between outpatient and inpatient treatment may also have helped reduce hospital emergencies.

The sharp decline in heart attacks that did not involve any interventions is likely due to various unusual features of 2020: On the one hand, patients with mild or unspecific symptoms presumably refrained from going to hospital for fear of becoming infected with COVID-19 or placing an unnecessary burden on the health system. On the other hand, doctors may have been more reluctant to refer patients to hospital for the same reasons. The consultations, some of which took place by telephone, also made diagnosis more difficult. The slowdown in everyday life following calls to stay at home enabled many people to experience a reduction in stress, which possibly contributed to the decline in heart attacks. The increased hygiene measures also reduced the incidence of respiratory infections, which can contribute to events such as heart attack or stroke.

 

 

Hospitalisations: Heart attacks



Source: Helsana
Changes in heart attacks examined in hospitals with and without invasive diagnostics.

“As with outpatient contact, many patients avoided hospital outpatient departments or even inpatient stays whenever possible. The effect was reinforced by the fact that there were already fewer consultations with referring GPs and specialists, with the result that there was also a huge decline in referrals.”

Professor Thomas Rosemann. Director of the Institute for Primary Care at the University of Zurich

Did check-ups for diabetics continue?

People with a chronic disease like diabetes usually have regular contact with the health system.

The treatment behaviour of diabetics seems to be independent of pandemic-related restrictions, with care continuing unchanged over the year as a whole. Depending on the recommended check-up, however, around 20% to 50% of diabetics did not comply with the guidelines, or did not receive medical care in accordance with the guidelines, as in the previous year. This proportion remains surprisingly high, and indicates significant potential for improvement independent of the pandemic.

 

HbA1c value (twice yearly): -2.4 percentage points 77.3%

Long-term blood glucose. Target value of 6.5% to 8.0%. Measurement of blood sugar concentration over the previous 2-3 months and thus the quality of diabetes compensation. Considered the gold standard in the diagnosis and monitoring of diabetes and for reducing the risk of complications.


Lipid values: +1 percentage point 65.8%

Blood lipid value. For the diagnosis of lipometabolic disorders. Poor values can lead to deposits on arterial walls, for example. Enables medical or lifestyle-related reduction in the risk of cardiovascular disease.


Kidney function: -0.7 percentage points 47.5%

Protein concentration in urine and creatinine content in the blood. Measurements for prognosis and follow-up of diabetic nephropathy (severe kidney damage).


Eye examination: -3.1 percentage points 45.9%

Detection of vascular damage to the retina and possibly throughout the body. Check-up by ophthalmologist to detect changes in the retina as early as possible and thus counteract gradual damage to the eye (e.g. diabetic retinopathy, loss of vision to blindness). The slight decrease in ophthalmology check-ups can possibly be explained by the fact that, according to the latest scientific findings, they can also be carried out every second year.


“Our own analyses based on daily HbA1c and blood pressure measurements carried out in practices reveal a decline in routine checks, especially in patients with chronic conditions such as diabetes and hypertension. This may be somewhat obscured by the annual perspective of this analysis. For possible future lockdowns, it will be important not to lose focus on these vulnerable groups.”

Professor Thomas Rosemann. Director of the Institute for Primary Care at the University of Zurich

Has the pandemic led to an increase in mental illness?

The pandemic is said to have been a difficult time for many in terms of mental health, and the media have also frequently reported an increase in mental health issues.

In general, around the same number of services were provided in outpatient psychiatry and psychology as in the previous year. Invoicing data show a more differentiated picture – as the pandemic had both negative and positive effects on people’s well-being, there is no clear trend but a partial shift between the treatment areas has been identified.

 

Crisis intervention by psychiatrists has increased

In the first wave, influenced by the sudden shutdown of social and economic life, treatment of acute mental crises by psychiatrists increased sharply. At the same time, however, it was less in demand from general practitioners. With more crisis intervention on the part of basic care providers than of psychiatrists on the whole, the decline in the former was more significant and was not completely offset by psychiatrists. In terms of crisis intervention, therefore, there was a partial shift from basic care to specialised care. The decline among GPs could be related to the significant reduction in practice availability during lockdown. Added to this is the fact that in an acute crisis, patients may have gone directly to a psychiatrist, who offered (video) telephone support from an early stage, thereby making access easier.

“There was a shift from face-to-face to telephone treatments. Psychiatrists probably made the transition faster than basic care providers, as the treatment format of telephone and video consultations is predestined for psychiatry and psychotherapy. People with more severe mental health conditions such as schizophrenia, bipolar disorder, severe depression or complex addictions treated by basic care providers were particularly affected by the stay-at-home instructions and regulatory restrictions on a personal level. Barriers to treatment were even higher than before the pandemic, and those affected may have received insufficient medical supervision during lockdown.”

Professor Erich Seifritz. Director and Senior Consultant at the University Hospital of Psychiatry Zurich

Average weekly number of crisis interventions by psychiatrists


1. Lockdown
2. Wave
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Source: Helsana
Crisis intervention among psychiatrists.

By contrast, initial psychiatric/psychological consultations generally have to take place in person, which was made very difficult by the “stay-at-home” requirement during the first wave. The number of initial consultations fell by almost 40% during this period as a result, whereas it was slightly above the previous year’s level during the second wave. It is to be assumed that only the very severe new cases found their way into regular psychiatric care during the first wave.

 

Children and young people were particularly affected

Children, adolescents and young adults, as well as people near retirement age were particularly affected psychologically by the pandemic and the measures imposed. They claimed benefits more frequently than the previous year, and do indeed appear to have been particularly challenged by the impact of the pandemic in terms of their mental health. This was presumably caused by fear of infection or transmission, and the social isolation caused by the restrictions. Added to this is the fact that suitable therapy places for children and adolescents were already in short supply before the pandemic. In this respect, it can be assumed that there was insufficient treatment for mental health issues and illness in this age group, despite an increase in consultations.

Were elective treatments cancelled altogether instead of being postponed?

Elective treatments are by nature services that can be planned and controlled. At the same time, however, this does not mean that they can be dispensed with completely. As non-urgent medical treatment was not permitted during lockdown, it is to be expected that these treatments or interventions will now be carried out as soon as possible.

 

Knee endoprosthesis: sufficient capacity in orthopaedics

The example of knee endoprosthesis shows that most specialists adhered to the official guidelines, and most elective procedures were postponed or cancelled during lockdown. A comparison with the previous year also shows that most of the postponed interventions were carried out by the end of the year. There appears to have been sufficient capacity to maintain the previous year’s level. An above-average number of operations were performed during the holidays, which were more likely to be spent in Switzerland or postponed. This confirms the common assumption that there is overcapacity in the area of orthopaedics in Switzerland.

 

Number of cases



Source: Helsana
Change in the use of knee endoprostheses.
 

Fewer vaccinations than officially recommended

The pandemic would not be expected to affect the basic vaccinations of young children recommended by the FOPH, even though it is an elective treatment. Neither parents nor young children are generally thought to belong to the risk groups likely to be affected by complications resulting from a COVID-19 infection. In addition to this, the authorities announced that check-ups and basic vaccinations would be carried out as planned. Despite this, however, there was a decline in certain vaccinations during lockdown. This was particularly true of the 5-in-1 basic vaccination provided before the age of nine months (diphtheria, tetanus and pertussis, Haemophilus influenzae type b and poliomyelitis) and the measles, mumps and rubella (MMR) vaccination. By the end of the year fewer children had been vaccinated against the corresponding disease risks than in the previous year.

 

The increased time that children spent at home and away from other children may have led parents to conclude that vaccination was less of a priority and therefore postpone it. Vaccination against hepatitis B, which children usually receive as part of a 6-in-1 vaccination, and against pneumococci, however, was administered with a frequency comparable to that of the previous year.

 

Measles, mumps and rubella vaccines for small children



Source: Helsana
Changes in measles, mumps and rubella vaccination in children up to 2 years of age.

“Vaccinations are typically carried out during a recommended check-up appointment. A decline in vaccinations suggests that there were also fewer check-ups. Among other things, check-ups make it possible to detect developmental delays, symptoms of more serious diseases and other abnormalities at an early stage and, together with vaccinations, represent one of the most important preventative measures in childhood. We should now aim to ensure that any missed preventative and screening appointments can be arranged.”

Professor Julia Dratva. Head of Research at the ZHAW Institute of Health Sciences

 

Cancer screening: no “cancer epidemic” to be expected

Older people form part of both the coronavirus risk group and the primary target group for cancer prevention from the age of 50. Standard cancer screening rates among adults fell significantly during the first wave with treatment restrictions and stay-at-home instructions. This was most pronounced in the context of mammography screening, where visits fell by 75%. This reticence continued for a while, until more check-ups were carried out in the summer between the two waves compared to the previous year. Although such check-ups can be seen as deferrable, none of the three cancer screenings studied reached the previous year’s level over the year, with a decline of between 3% and 7% in breast, bowel and prostate cancer screening.

 

In an ideal scenario, the pandemic will have led to the optimisation of the triage process, with screening only being carried out for the recommended age groups and, in the case of prostate screening, following decision-making together with patients. If even better use is made of screening in the future on the basis of risk-specific factors, it should be possible to reduce the number of false positives, which are stressful for those affected.

 

Breast cancer screening


1. Lockdown
2. Wave
Jan
Feb
Mar
Apr
May
June
July
Aug
Sept
Oct
Nov
Dec
Source: Helsana
Number of mammograms performed.

4. Conclusion

It is not just medicine and healthcare provision that are essential for health – individual behaviour and living conditions also play a significant role. This is the case regardless of the financial and material resources flowing into the health system. The behaviour of the population has changed in the wake of coronavirus, with stress levels falling in many cases for example, and increased awareness of hygiene and distance leading to fewer respiratory infections. These factors have had a positive effect on a variety of diseases.

 

For all the analysis, however, figures alone say little about the extent and quality of medical care. It is important to ensure that access to necessary treatment and therapy facilities can continue even during a period of restriction. To prevent the risk of diseases deteriorating in the long term, it is important not to neglect examinations, preventative measures and interventions. The analysis suggests that the health system was largely resilient during the pandemic, and that it continued to provide medical care despite the situation. The Helsana report on the effects of the coronavirus pandemic on medical care in Switzerland provides an initial assessment of the situation. Further analysis must now follow. The key concern of the report is to provide a basis for and to encourage such efforts and discussions. The task now is to use the insights of this report to help promote a well-developed, affordable health system for all in Switzerland.

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Differenz der OK (chart1)

Differenz der OKP-Leistungen zwischen 2019 und 2020 pro Kostenkategorie (chart11)

Differenz OKP-Leistungen 19-20 in % (chart2)

11 Art der Konsultationen beim Grundversorger (char31)

4 med (chart4)

17 Kriseninterventionen beim Psychiater (chart5)

6 psych diff (chart6)

7 Knieend (chart7)

8 MMR Impfungen (chart8)

9 Mammographie (chart9)

rt5